Developed by
Jeffrey Young, Ph.D.
Name______________________________________________
Date____________________________
INSTRUCTIONS: Listed below are statements that you might use to describe your parents.
Please read each statement and decide how well it describes your parents. Choose the highest
rating from 1 to 6 that describes your mother, then your father, when you were a child and
write the number in the spaces before each statement. If someone substituted as your mother or
father, please rate the scale for that person. If you did not have a mother or a father, leave the
appropriate column blank.
1 = Completely untrue
2 = Mostly untrue
3 = Slightly more true than untrue
4 = Moderately true
5 = Mostly true
6 = Describes him/her perfectly
MOTHER FATHER DESCRIPTION
__________ __________ 1. Loved me, treated me as someone special.
__________ __________ 2. Spent time with and paid attention to me.
__________ __________ 3. Gave me helpful guidance and direction.
__________ __________ 4. Listened to me, understood me, shared feelings with me.
__________ __________ 5. Was warm and physically affectionate.
__________ __________ 6. Died or left the house permanently when I was a child.
__________ __________ 7. Was moody, unpredictable, or an alcoholic.
__________ __________ 8. Preferred my brother(s) or sister(s) to me.
__________ __________ 9. Withdrew or left me alone for extended periods.
__________ __________ 10. Lied to me, deceived me, or betrayed me.
__________ __________ 11. Abused me physically, emotionally, or sexually.
__________ __________ 12. Used me to satisfy his/her needs.
__________ __________ 13. Seemed to get pleasure from hurting people.
__________ __________ 40. Made me feel that almost nothing I did was quite good enough.
__________ __________ 41. Had strict, rigid rules of right and wrong.
__________ __________ 42. Became impatient if things weren't done properly or quickly enough.
__________ __________ 43. Placed more importance on doing things well than on having fun or relaxing.
__________ __________ 44. Spoiled me, or was overindulgent, in many respects.
__________ __________ 45. Made me feel I was special, better than most other people.
__________ __________ 46. Was demanding; expected to get things his/her way.
__________ __________ 47. Didn't teach me that I had responsibilities to other people.
__________ __________ 48. Provided very little discipline or structure for me.
__________ __________ 49. Set few rules or responsibilities for me.
__________ __________ 50. Allowed me to get very angry or lose control.
__________ __________ 51. Was an undisciplined person.
__________ __________ 52. We were so close that we understood each other almost perfectly.
53. I felt that I didn't have enough individuality or sense of self separate from
__________ __________
him/her.
54. I felt that I didn't have my own sense of direction while I was growing up beca
__________ __________
he/she was such a strong person.
__________ __________ 55. I felt that we would hurt each other if either of us went away from the other.
__________ __________ 56. Worried a lot about the family's financial problems.
__________ __________ 57. Made me feel that If I made even a small mistake, something bad might happe
__________ __________ 58. Had a pessimistic outlook; often expected the worst outcome.
__________ __________ 59. Focused on the negative aspects of life or things going wrong.
__________ __________ 60. Had to have everything under control.
__________ __________ 61. Was uncomfortable expressing affection or vulnerability.
__________ __________ 62. Was structured and organized; preferred the familiar over change.
__________ __________ 63. Rarely expressed anger.
__________ __________ 64. Was private; rarely discussed his/her feelings.
__________ __________ 65. Would become angry or harshly critical when I did something wrong.